I was sitting in my office at the outpatient ob/gyn office I was rotating through, gulping down as many sips of coffee I could before the lovely medical assistant could throw another intake chart at me. I was not sure how many patients I had seen that day; it was more than I could count. 

The medical assistant came in, smiled at me, and told me the patient was OK with having a medical student see her. I looked at her chart: “G2P1.” I briefly looked through the notes available in her chart. It seemed as though she was currently 38 weeks pregnant and had an additional child at home. Ever the optimist, I walked into the room where she sat with her husband. She was out of breath and exhausted, leaning back with both hands on the bench to support her massive pregnant belly. I smiled at her and introduced myself. 

“You look exhausted,” I said, as I pulled my stool closer to her with her intake form. 

“I am so tired.” She giggled as she said this, but her husband looked very nervous. I went over the standard questions we are supposed to ask women at 38 weeks of pregnancy — questions about headaches, abdominal pain, nausea, vomiting, contractions, swelling — and then asked if she had any other questions. She looked at me and told me she was fine overall. “Is this baby too big?” she asked.

I reviewed the fetus’ growth on the anatomy scan with the patient and told her it was unlikely that the baby was too big. I measured her fundal height (even though it was unlikely to tell me anything of use), but it was within normal limits at this gestational age.

“I just want to make sure that the baby will come out vaginally,” she said. 

I explained that there was really no way to know ahead of time which way a baby would come out, unless there were specific diagnoses, none of which she had. I let her know that our hospital always tried for vaginal deliveries when it was safe and if that’s what she wanted. She did not seem reassured and continued to ask me questions. I looked down at her chart. 

“Many times, when women have previously delivered vaginally, they are able to do so again,” I told her. “You’ve been pregnant once before, right?” I was hunting for an answer to show her that she had what obstetricians commonly call “a proven pelvis,” and that the baby she was growing now would likely be able to come out vaginally. 

She responded: “Yes, but that baby was premature.” There was something about prematurity in the chart. 

“How premature was the baby?” I asked. 

She looked at me and told me the baby was 26 weeks premature. There was a possibility that the baby was all right. There was also a possibility that the baby was not. 

I gently asked her, “Is that baby … OK?” There was hesitation in my voice. She shook her head no, and her husband shed a tear and told me it was a stillbirth. 

I sat down for what felt like forever thinking about that moment. I was flustered and angry. I had betrayed this woman. I briefly searched through the medical record to see if that had been documented anywhere. Nothing. Why did I not know this woman had had a stillbirth? I was embarrassed that I had even brought it up. This woman’s baby would likely live, and she was already term. No matter how we got this baby out, there was a good chance the baby would go home healthy and lead a very normal life. But I had just traumatized this woman and her husband by stirring up memories of what was likely one of the worst days of her life. I had reminded her of one of the worst days of her life, in what was supposed to be a time of joy.

Was the stillbirth documented incorrectly? Technically, no. She was indeed “G2P1”: She was currently pregnant and had been pregnant once in the past: two times gravid. And her stillborn child had been born after 20 weeks with vaginal delivery: once parous. 

But there was nothing in the documentation, as there often should be, about the fate of this child. No note for me to acknowledge to help her quell her anxieties. There was only another dead baby we forgot to write about. No wonder she was nervous. I would be nervous every day of that pregnancy. 

Ultimately, I was the one who updated her chart with a note that would be accessible to her whole care team, from ongoing prenatal visit clinicians to the delivery team: “Handle with care — hx of stillbirth at 26 weeks, first pregnancy after.” It was one short sentence — one statement that would make medical care a little bit more humane for this woman who had suffered. I wondered how many seemingly benign comments we made to her throughout this pregnancy that worried her without our knowing. I wondered how many therapy appointments she’d missed out on because we didn’t write the note. I wondered how deeply we had let her down, and whether or not we’d be able to help pick her back up again. 

Have you encountered cases where patients' records did not tell the whole story? Share your experiences in the comment section.

Micaela Stevenson is a fourth-year medical student at the University of Michigan. She is planning to go into obstetrics and gynecology with a subspecialty in reproductive endocrinology and infertility. You can find her on instagram @babydocatyourcervix.

Illustration Collage by Jennifer Bogartz / Ponomariova_Maria / gettyimages